Louisiana Pharmacies’ Availability of Emergency Contraception and Counseling Accuracy to Adolescent and Physician Callers

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ABSTRACT

Study Objective

Adolescents face many barriers to obtaining emergency contraception (EC), despite it being an approved and recommended method to prevent unintended pregnancy. This study examined pharmacy-related barriers to adolescents’ access to EC in Louisiana.

Design

Prospective, telephone-call secret shopper study to pharmacies to assess same-day EC availability and barriers to purchase.

Setting

A total of 182 pharmacies in 5 Louisiana cities.

Participants

Responses provided by pharmacists or other pharmacy staff assessed between July 2018 and November 2019.

Interventions

Collected data from secret shopper phone calls and compared responses provided to callers between male and female callers and physician and adolescent callers.

Main Outcome Measures

Same-day levonorgestrel (LNG) availability, same-day ulipristal acetate (UPA) availability, age restrictions on purchase, requirement of parental consent for purchase, and type of staff member that advised the caller.

Results

Of 364 calls to 182 pharmacies, 66% of pharmacists or other pharmacy staff reported same-day LNG access and 5% reported same-day UPA access. An inaccurate age restriction regarding EC purchase was reported in 15% of calls. Female callers were cited this age restriction more frequently than their male counterparts (20% vs 10%). Pharmacists were more likely than other pharmacy staff to counsel female callers compared to male callers (52% vs 27%) and physician callers compared to adolescents (50% vs 30%).

Conclusions

Many pharmacies in Louisiana have limited same-day availability of EC and often report inconsistent and inaccurate age and consent regulations for its use. Continued outreach and education to pharmacies is necessary to address these barriers to adolescent EC access.

Introduction

Unintended adolescent pregnancy can have a negative impact on both parent and child by increasing barriers to educational attainment, economic stability, and optimal health outcomes.1,2 Fortunately, adolescents’ access to contraception has steadily increased over the years and remains a viable method to reduce rates of unintended pregnancy.3 Over the last 20 years in the United States, rates fell from 51.3 births per 1000 female individuals aged 15-19 years in 1997 to 17.4 births per 1000 in 2018.4., 5., 6. Both the American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG) recommend access to various forms of contraception to adolescent patients, including emergency contraception.7., 8., 9., 10.

Emergency contraception (EC) is used after both unprotected intercourse and sexual assault to prevent unintended pregnancy, and comes in 3 main forms in the United States: a copper intrauterine device, oral ulipristal acetate (UPA), and oral levonorgestrel (LNG).11 UPA 30 mg is the newest form of EC and can be used up to 120 hours after unprotected intercourse. UPA is available only with a prescription in the United States and provides better efficacy than LNG for women with higher body mass indexes.11., 12., 13. LNG 1.5 mg is an older form of EC that should be used within 72 hours after unprotected intercourse for maximum efficacy, although studies support the use of LNG up to 120 hours after intercourse to prevent unintended pregnancy.10 In addition, since 1974, 2 doses of an estrogen and progestin combination taken twice 12 hours apart (termed the Yuzpe method) can be used as an off-label form of emergency contraception.14 Since 2013, LNG has been available for over-the-counter sale and without age restrictions.15,16

Despite the removal of age restrictions on LNG, many adolescents continue to face barriers when trying to access EC. For example in one study, adolescents accessing EC in low-income neighborhoods were more likely to be denied due to pharmacy staff citing an inappropriate age restriction than were adolescents in high-income neighborhoods.15 In addition, poor understanding of the types and utility of EC by both medical providers and pharmacists prevents access for adolescents.17,18 Finally, UPA is simply not stocked by many pharmacies (only 2.6%-10% of pharmacies in some cities), so that a prescription for UPA does not guarantee that a patient will receive it in time to prevent an unintended pregnancy.13,16,17

Louisiana was chosen to represent states in the Deep South of the country that have been established to have poorer reproductive health outcomes.19 States in this geographic region have been found to have the highest teen pregnancy, birth rates, and STD rates.20 For example, Arkansas, Mississippi, and Louisiana were the 3 states that had the highest teen birth rates in the country in 2018.21

The purpose of this study was to determine the same-day availability of LNG and UPA in Louisiana reported to male or female and adolescent or physician callers and any misinformation provided by pharmacies regarding adolescent access of EC.

Section snippets

Material and Methods

Two female researchers and one male researcher conducted secret shopper calls to pharmacies using the standardized script shown in Figure 1. For each call, the researcher posed as either an adolescent or a physician calling on behalf of an adolescent patient. The “adolescent” or “17-year-old” caller gathered data regarding same-day access to LNG and UPA, any age-restrictions on purchase, the requirement of parental consent, cost of drug, and role of the pharmacy staff member with whom they were

Results

The 3 largest cities in the sample (New Orleans, Baton Rouge, and Lafayette) received between 20% and 30% of call volume each, representing 48, 42, and 36 of the 182 total pharmacies, respectively. The 2 smaller cities (Monroe and Houma) received approximately 15% of call volume each, representing 31 and 25 of the 182 total pharmacies, respectively. Female and male callers each made half of the calls, and roughly half of the calls were split into the role of an adolescent caller or a physician

Discussion

Results from this investigation suggest that roughly two-thirds of pharmacies in Louisiana offer same-day availability of EC. Unfortunately, this is much lower than in other parts of the United States, which range from 78% to 90% of pharmacies.23., 24., 25., 26., 27. The large difference in LNG availability (66%) versus UPA availability (5%) in this study is not surprising, because of the over-the-counter status of LNG and the fact that UPA is a newer drug, requires a prescription, and requires

Acknowledgments

We thank Mr. James Aden (San Antonio Uniformed Services Health Education Consortium) for his assistance in the data analysis of this paper.

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  • Cited by (3)

    • The impact of caller characteristics on levonorgestrel emergency contraception access in West Virginia community pharmacies

      2022, Sexual and Reproductive Healthcare
      Citation Excerpt :

      Pharmacy staff are blinded to the true purpose of the call allowing researchers’ experiences to better reflect those of consumers [13–15]. Some studies have found that female teen callers are more likely to be told that LNG EC is not in stock and to experience barriers to purchase than other types of callers (e.g., male teens, callers posing as physicians) [12,16]. Other studies show increased barriers at independent pharmacies compared to chain pharmacies, and in lower socioeconomic status regions as compared to higher [1,2,6–12,16–17].

    The authors do not have affiliations, financial agreements, or conflicts of interest to disclose as reported in the manuscript.

    Support was provided in part by grants 2015-62389 and 2018-67794 from the David and Lucille Packard Foundation Population and Reproductive Health Program, which funds the Reproductive Education + Advocacy Louisiana (REAL) program. The content is solely the responsibility of the authors and does not necessarily represent the official views of the David and Lucille Packard Foundation.

    The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

    Data were previously presented at the following: Southern Society for Pediatric Research, New Orleans, LA, February 21-23, 2019 (oral presentation); Society for Adolescent Health and Medicine National Meeting, Washington, DC, March 6-9, 2019 (poster presentation); and Healthy Teen Network Conference, New Orleans, LA, October 27-30, 2019 (poster presentation).

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